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ywamburtigny.com
Isaiah 58:10
"Pour yourself out for the hungry
and start giving of yourself
to the down and out"
Esaïe 58.10
"Engage-toi en faveur des
affamés et dévoue-toi
pour les opprimés"
Student Application B
Student Application (Part B)
Please type out your responses in a text editor so that if you lose any information, you can repaste it into the form
First and Last Name
(required)
Email
(valid email required)
Name of your local church
(required)
Denomination
Your pastor's name:
(required)
How long have you attended this church?
The address for your church:
(required)
Your Church Telephone Number
Your Church Fax Number:
Does your pastor approve of you applying for this school?
Yes
No
Please give details of your education and traning
(required)
Do you have any diplomas or degrees from your studies?
Any other skills, competencies and abilities you have. Including interests.
Do you have a driver's license?
(required)
What languages do you speak?
(required)
Are you a student of the University of the Nations with the purpose of obtaining a degree?
Yes
No
What other schools have you done with the University of the Nations, or what other experience do you have from working with YWAM
(required)
Medical Information
Your Health Insurance Details
Medical Insurance Number
Do you consider yourself healthy?
(required)
Do you suffer from any of the following symptoms?
Back Problems
Visual Problems
Hearing
Migraines
Epilepsy
Mental or Neural
Insomnia
Heart Problems
Asthma
Hay Fever
Allergies
Cardiac
Hypertension
Tension basse
Rhumatism/Arthritis
Stomach Ulcers
Hepatitus
Diabetes
Cancer
HIV/Aids
Depression
Fatigue Chronique
Immune Problems
Indicate other health problems or sicknesses that we need to know about?
(required)
Are you on any medicine ? Yes / No (If so, please explain)
Yes#No
(required)
Do you have any other ailments or are you being treated for anything right now ? Yes / No (If so, please explain)
(required)
Are you allergic to any medication ? Yes / No (If so, please explain)
(required)
Do you suffer from any deficiency, handicap, or state of health that would require special housing, food or special care?
(required)
Are you above or below your normal weight range?
(required)
Medical agreement: in case of urgency, I/us undersigned grants all necessary treatment, including the anesthetics and all operations advisable by the doctor or the surgeon.
no, I don't agree
yes, I agree
In emergency, please contact
(required)
Finances
that you will cover the cost of the school.
(required)
Do you have any debt at the moment? Yes/No, if yes, please give details.
(required)
Recognition of Responsibility
No, I cannot commit to take responsibility for my finances
Yes, I will take responsibility for the financial implications and costs of the school
Release of Responsibilities
Non, je ne donne pas mon accord
Oui, je donne mon accord
Please email me a copy of this form
Please enter the verification code before submission
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